Commonwealth Care Alliance

Commonwealth Care Alliance

Providers > Provider Manual > Benefit Exhaustion

Benefit Exhaustion

Benefit Exhaustion of Sub-Acute Care and Skilled Care

If during an admission the exhaustion of a member’s Medicare skilled nursing benefit occurs, Commonwealth Care Alliance reimbursement shall default to provider’s usual and customary Medicaid reimbursed MMQ rates, based on the member’s MMQ score, for skilled nursing facility placement less the applicable MassHealth determined monthly member paid amount.

Readmissions

Member readmission to facility after formal discharge shall require re-establishing a member’s admitting level of care by Commonwealth Care Alliance clinical operations staff, PCT, and/or those designated and authorized by Commonwealth Care Alliance to direct member care.

Level of Care Determinations

All level of care determinations prior to, and during Commonwealth Care Alliance member’s admission to a facility, are made at the discretion of Commonwealth Care Alliance nursing staff and/or those designated and authorized by Commonwealth Care Alliance to direct member care.

Medical Leave of Absence (MLOA) days and Non- Medical Leave of Absence (NMLOA) days will be paid an amount equal to the provider’s current Medicaid reimbursement rate for up to 10 days with the prior approval of the member’s Commonwealth Care Alliance contracted PCP/PCT. It is further understood, and agreed, that a bed is guaranteed for the member if s/he returns to the facility during the 1st day through the 10th day after transfer out of the facility. If the member returns after this period, his/her admission shall be accommodated upon the availability of a bed, unless otherwise arranged. For billing purposes of Custodial MLOA, please use Revenue Code 185. For billing purposes of Custodial NMLOA, please use Revenue Code 183.

Service Specifications

The extended care facility services provider shall:

  1. Maintain 24 hours a day, 7 days a week availability to provide extended care facility services in accordance with state and federal regulations, and be accessible by phone, directly, at all times.
  2. Upon request, provide admission for extended care facility services within 24 hours of the request subject to bed availability and with the prior authorization of Commonwealth Care Alliance nursing staff and/or those designated and authorized by Commonwealth Care Alliance to direct member care.
  3. The provider agrees to maintain and respect the rights of members at all times.
  4. Inform Commonwealth Care Alliance nursing staff and/or those designated and authorized by Commonwealth Care Alliance to direct member care as to the availability of beds upon their request.
  5. Ensure that personnel providing services under this agreement meet current applicable federal, state, and local licensing standards for the provision of healthcare services, and are fully Massachusetts state-credentialed health care providers; provider agrees to notify Commonwealth Care Alliance of changes in status that would disqualify provider(s) from meeting above standards.
  6. Provider is responsible for delivering the Notice of Medicare Non-Coverage (NOMNC) on behalf of Commonwealth Care Alliance no later than 2 days before a member’s level of care is changed from skilled to custodial or covered services end (discharge) in accordance with Medicare requirements.
  7. Provide extended care facility services to members in conformance and full cooperation with the treatment plan developed by the PCP/PCT. Facility agrees to allow the member’s PCP or designee to continue as the member’s physician of record.
  8. Contact the PCP/PCT immediately, upon notice of significant changes and/or relevant findings concerning the status of the member.
  9. Conform to Commonwealth Care Alliance’s protocols for timely updates and submissions of SC1, MDS, MMQ, and medications list forms upon Commonwealth Care Alliance request; provide the PCT and/or Commonwealth Care Alliance with timely clinical updates appropriate to the member’s status in a mutually agreed upon format and frequency.
  10. Agree to meet with PCT clinical staff as needed.

 

Last Updated 07/28/2014